final from quizlet Flashcards
1
Q
primary intention healing
A
primary intention healing
wound edges are well approximated with minimal to no tissue loss
“hairline” scar
2
Q
secondary intention
A
wound edges are unable to be easily approximated, typically a gaping wound with significant tissue loss
leaves a large scar
3
Q
pressure ulcer etiology
A
unrelieved pressure resulting in disrupted blood supply to an area
(friction, shear, supply and moisture)
4
Q
venous insufficiency
A
inability of the veins to adequately return blood from the lower extremities
(blood pooling & edema)
5
Q
surgical dehiscence
A
opening of previously closed wound
6
Q
what contributes to the development of wounds
A
- pressure INTENSITY
- pressure DURATION
- tissue TOLERANCE
- know the cause to prevent recurrence
7
Q
stage 1 pressure injury
A
non-blanchable erythema of intact skin
8
Q
stage 2 pressure injury
A
partial thickness tissue loss showing pink or red viable tissue, moist, with a distinct wound margin
slough/eschar NOT present
9
Q
stage 3 pressure injury
A
full thickness tissue loss with just subcutaneous adipose tissue layer exposed
slough/eschar present
10
Q
stage 4 pressure injury
A
full thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone
11
Q
unstageable pressure injury
A
dry, stable eschar firm cap OR moist, boggy eschar cap
12
Q
deep tissue injury
A
dusky, boggy or discoloured area of purple, maroon, ecchymosis or a blood-filled blister
13
Q
what does the Braden Scale assess?
A
pressure sore risk
14
Q
full thickness wound repair phases
A
- INFLAMMATORY PHASE : hemostasis, clots form, mast cells secrete histamine
- PROLIFERATIVE PHASE : new blood vessel appear, fill with granulation tissue, fibroblasts synthesize collagen
- REMODELING : maturation, can take up to 2 years
15
Q
how do you measure a wound?
A
length x width x depth
sinus tract (narrow channel or passageway) and measure using a clock format (pts head is 12:00)
undermining (open area extending under intact skin along edge of wound
ALL IN CM
16
Q
wound irrigation
A
flushing of an open wound using a solution such as sterile saline or sterile water
30-35 cc syringe with wound irrigation tip
use approximately 100 cc to flush wound bed or until solution runs clear
17
Q
what is the purpose of wound packing?
A
to loosely fill dead spaces
facilitate the removal of exudate and debris
encourage the growth of granulation tissue from base of wound to present premature closure and abscess formation
18
Q
complications of over packing a wound
A
will cause pressure on wound tissue that can cause pain, impair blood flow and further damage
19
Q
complications of under packing a wound
A
may result in rolled wound edges and/or abscess formation
20
Q
peri-wound skin
A
skin around the wound
21
Q
indications for indwelling catheters?
A
- urinary retention
- short-term monitoring of urinary output
- peri-op and intra-op monitoring of output
- facilitate healing of pressure ulcers in incontinent pts
- requires prolonged immobilization
- improve comfort (end of life care)
22
Q
what are in and out catheters used for?
A
single lumen foley
used for short-term use, does not remain in the bladder
23
Q
what are two way foley catheters used for?
A
double lumen foley
used longer term, balloon inflates and it remains in the bladder
24
Q
what is a three-way foley catheter used for?
A
triple-lumen foley
used for bladder irrigation
25
what is a coude catheter used for?
used when there are difficult insertions such as a pt with BPH
26
what position is best for patients when inserting a foley catheter?
male: supine and legs extended
female: dorsal recumbent
27
once urine starts flowing out of the catheter, how much further do you insert before inflating the balloon?
2.5-5cm
28
how can you present a CAUTI?
- proper peri-care pre insertion
- maintain aseptic technique
- sterility of insertion
- promote a one-way flow of urine (stat lock in place, bag below bladder and above floor)
- new drainage container every 24 hrs
29
what order do you put in a foley catheter?
1. clean gloves to perform peri-care
2. hand hygiene
3. open foley kit, position drape under the buttocks
4. drop foley onto the sterile field
5. pour antiseptic solution into the container of cotton balls
6. don sterile gloves
7. lubricate catheter
8. drape over the perineum
9. place sterile contents on the drape
10. cleanse the meatus
11. insert catheter
12. inflate balloon
13. pull gently until resistance is felt
14. attach drainage end of the catheter to collecting tubing
15. secure catheter using stat-lock
30
what is closed bladder irrigation used for?
prevent or remove clots post-surgery in the urinary system
31
what instructions would you give to a patient after a foley removal?
1. increase fluid intake
2. need to void within 6-8 hrs post removal
3. measure first void
4. some irritation may be present upon first void
5. try to empty bladder fully
32
what is a nasogastric tube?
tube inserted through one of the nostrils, down the nasopharynx, down the esophagus and into the stomach
33
what is an NG tube used for?
(large bore tube: salem sump)
used for gastric decompression (draining the stomach) & medications
34
what are EN tubes used for?
(small bore tube)
used for feeding & medications
35
what should you assess prior to inserting an NG tube?
- indication
- hx of facial trauma/basal skull fractures
- esophageal varices
- deviated septum
- coagulation studies
- visual assessment of patency of nares
- GI assessment
36
how do you determine the length of an NG tube for insertion?
measure from the tip of the nose, to the earlobe, to the tip of the xiphoid process
37
how do we determine the correct placement of the NG tube?
1. withdraw gastric contents and test the pH
2. chest x-ray
38
what should the pH of the gastric contents be?
1.5-5 (if greater than 6 it is likely from the lungs)
39
ongoing NG tube care/management
1. pH check
2. external measurement check
3. inspection of nostrils (eg. irritation, adhesion of tape)
4. resp assessment
5. GI assessment
6. mouthcare
7. connection to suction (as per dr's orders)
40
what should you do if a pt starts coughing during the NG tube insertion?
remove and try again
41
what should you do if a pt is uncomfortable during the NG tube insertion?
you can ask them to swallow, give them a cup of water and a straw to sip on during the insertion
42
where is the nasoenteric tube placed & why?
duodenum, reduces aspiration risk
43
what position should the pt be in for insertion of an EN tube?
High Fowlers
44
possible complications of enteric feeds
- tube placement
- tube occlusion
- abdominal cramping, nausea, vomiting
- diarrhea
- pulmonary aspiration
45
how can you prevent pulmonary aspiration?
- sit straight up when tube feeding
- keep the head of the bed at least 30 degrees
- perform oral care routinely
46
describe the process of flushing meds through an EN tube
1. flush with 30 cc's of water before meds
2. mix each med with 15 - 30 cc's
3. admin the med
4. flush with 30 cc's between all meds
47
what are the two system types for feeding solutions?
1. OPEN: pour solution into a bag and prime tubing
2. CLOSED: prepared bag which you spike with tubing
48
what frequency types may be used for feeding?
1. INTERMITTENT
2. CONTINUOUS
3. SYRINGE (infants)
49
gastrojejunal (GJ) tubes
used long-term
inserted surgically
port is outside of the body, into the stomach, tube goes down into the jejunum
prevents aspiration risk d/t placement
50
ostomy
surgical procedure resulting in the external diversion of feces or urine through an abdominal stoma
can be temporary or permanent
51
ileostomy
opening in the ileum, typically in the RLQ
creates looser stools
52
urostomy
small piece of ileum is attached to the ureters and stoma is brought out
53
nephrostomy
tube placed directly into the renal pelvis to drain urine
54
loop ileostomy
proximal and distal opening
usually temporary
may have a rod post-op
55
end ileostomy
initially sutured, sutures should fall out on their own
56
what is the normal ileostomy output
500-750 mLs daily (depending on intake)
toothpaste to oatmeal consistency
57
are laxatives, suppositories or enemas recommended for ileostomy's?
NO
stool is usually too liquid, stoma has no sphincter to allow for suppository retention
58
when should you empty the ileostomy bag and how often per day?
empty when 1/3-1/2 full
important as the enzymes contained in the liquid stool can damage the peri-stomal skin
typically 4-6x per day
59
what type of diet should a patient with a recent ileostomy be on?
low fibre diet
extra fluids and electrolytes due to higher fluid loss
60
pt education on partial/complete ileostomy obstruction
there is a risk for food blockage
SYMPTOMS:
no output or high liquid output in 12 hrs
cramping, bloating, nausea
MANAGEMENT:
go to emergency
61
colostomy
opening in the colon, typically in the LLQ (descending colon)
creates more solid stools
62
colostomy dietary considerations
no need for specific changes, recommend a balanced diet
HOWEVER
some foods may increase gas or odour (broccoli, cauliflower, cabbage, brussel sprouts)
if gas is a problem avoid (talking while eating, carbonated beverages, drinking through straws)
63
what foods may help thicken stoma output?
yogurt, cheese, white bread, potatoes, pasta, bananas, pasta, white rice, applesauce
64
is there a change in medication absorption with colostomies
NO
65
normal output for colostomies
1-3 movements daily
semi-formed to formed
66
ileostomy/colostomy reversal
minimum 3 months after initial surgery
some diarrhea is normal after reversal
67
normal output for urostomies
1000-2000 mLs daily
yellow with mucous shreds
68
what does the ideal stoma look like?
2.5 cm tall
red/pink, moist, round
smooth surface below belt line
69
describe the process of changing an ostomy pouch
1. empty pouch
2. position client
3. remove old appliance
4. clean (only warm water)
5. measure stoma
6. cut pattern
7. remove film from flange and secure over stoma
8. attach pouch
70
chemical damage of peri-stomal skin
due to output in contact with skin
change appliance, powder and no-sting spray to help heal areas
71
mechanical damage of peri-stomal skin
due to inappropriate removal or flange/tape
teach a traumatic appliance removal and teach gentle skin care
72
fungal rash damage to peri-stomal skin
due to persistent skin moisture or abx use
keep skin try and topical antifungal powder & sealant as indicated
73
pseudoverrucous lesions to peri-stomal skin
chronic exposure to urine or moisture, creates lesions
ensure a correctly fitting appliance, consider extended wear barrier
74
pyoderma gangrenosum to peri-stomal skin
dysregulation of immune system, 3 P's (pain, purple, pus)
non-tramatic wound care, topical steroids, systemic steroids
75
mucocutaneous separation
breakdown of suture line securing the stoma to abdominal surface
management is conservative wound care
76
prolapse stoma
due to excessively large opening in abdominal wall or increased abdominal pressure
modify pouch to accommodate the wider diameter & increased length of stoma
may require surgical intervention
77
peristomal hernia
protrusion of bowel into subcutaneous tissue
hernia belt, flexible flange
78
flush/retracted stomas
insufficient stomal length
treat with belts or rings, or surgical revision when indicated
79
what do you do if a stoma is located in a crease/fold?
fill the creases for flat adhesion or use of a belt
80
S&S associated with hypoxia and hypercapnia
- Low O2 sats
- tachycardic, hypertensive, tachypneic
- anxiety
- decreased LOC & ability to concentrate
- lethargy
- dizziness
- pallor/cyanosis
81
oropharyngeal suctioning
removal of secretions from the throat with a Yankauer suction catheter through the mouth
encourage client to cough, rinse with water
82
nasopharyngeal and nasotracheal suctioning indications
1. to maintain a patent airway and remove saliva, pulmonary secretions, blood, vomit, or foreign material from trachea
2. to stimulate cough
3. to obtain a sputum sample for lab analysis
83
what position should a pt be in before suctioning
Semi-Fowlers or sitting upright
84
what rate should the suction be set at when doing nasotracheal/pharyngeal suctioning?
80-100
85
describe the process of nasotracheal suctioning
1. attach to wall suction (80-100 mmHg)
2. lubricate the end, insert into the nares approx 20 cm WITHOUT suctioning
3. intermittent suction and rotate catheter upon removal for 10-15 seconds
4. flush with sterile NS/water
5. re-apply oxygen to oxygenate, wait 1 minute if another pass is required, limit to 2 passess
86
blood component
therapeutic component of blood (eg. RBCs, platelets, plasma and cryoprecipitate)
87
blood product
any therapeutic product derived from human blood or plasma and produced by a manufacturing process (eg. albumin, immunoglobulin preparations, and coagulation factors)
88
what is the shelf life of blood
35-42 days
89
when is consent NOT required prior to a blood transfusion?
when urgent treatment is necessary to preserve a patient's life and continuing health and it is not reasonably possible to obtain consent, and there is not substitute decision maker
90
what should be included in the blood product order
1. number of units or volume in mLs required
2. rate or duration of the infusion
3. special requirements
91
what IV gauge is recommended for blood product transfusion?
18-20 gauge (can use 22)
large enough to allow flow rate and avoid cell damage
92
pre-transfusion patient assessment
within 30 mins of transfusion, BEFORE spiking blood product
looking for any clinical manifestations that may delay transfusion or may be confused with a transfusion reaction (eg. fever or pre-existing rash)
record baseline vital signs, chest auscultation and review of fluid balance for high risk patients
93
what administration set is used for blood infusions?
blood infusion set with micron filter to administer RBCs, platelets, plasma and cryoprecipitate
94
what administration set is used to administer IVIG and albumin?
primary infusion set
95
what solution is compatible with blood?
NS
96
what other assessments do you need to complete prior to a transfusion?
1. visually inspect blood product for leaks, abnormal color, excessive air or bubbles, evidence of hemolysis, clots or clumping
2. verify consent
3. check blood product order
4. patient and product checking procedure as per agency policy
97
how soon after removing the blood product from temp controlled storage should you administer?
within 20 minutes
98
what rate should you administer a blood product at?
1ml/kg/hr up to a max of 50 ml/hr for the first 15 minutes
if no s/s or a transfusion reaction occur during the first 15 minutes then adjust the flow rate
99
patient monitoring during a blood transfusion
directly observe pt for 15 minutes for s/s of a transfusion reaction
record vital signs (15 min after start, 60 mins after start, and hourly)
100
how long is a blood tubing set good for?
2 units, or 4 hours
101
what are s/s of a transfusion reaction
fever, hypotension, rigors, anxiety, chest pain, nausea/vomiting, dyspnea, tachycardia/arrhythmias, flushing, rash, urticaria, hypothermia, headache/muscle pain
102
acute hemolytic reaction
develops within the first 15 mins
s/s are: chills, fever, lower back pain, tachycardia, tachypnea, and hypotension
103
febrile, non-hemolytic transfusion reaction
caused by cytokines released from blood donor WBCs
s/s: fever/and or chills during or up to 4 hours post-transfusion
104
mild allergic transfusion reaction
hypersensitivity to plasma proteins
s/s: flushing, itching, hives
105
anaphylactic transfusion reactions
more severe than a mild allergic reaction
antibody-antigen reaction
106
circulatory overload transfusion reaction
Transfusion too large causing hypervolemia
s/s: coughing, cyanosis, difficulty breathing
107
sepsis transfusion reaction
caused by a bacteria or bacterial byproducts which may contaminate blood
108
nursing interventions for a suspected transfusion reaction
1. STOP transfusion, do NOT admin remaining blood in the line
2. administer 0.9% NS
3. vital signs, seek help
4. reconfirm pt identifiers and blood product
5. call blood lab immediately if an error occurred
6. administer resuscitative care
7. report suspected reaction
109
what to do when the transfusion is completed?
1. STOP when bag is empty
2. flush administration set with 0.9% NS
3. disconnect line
4. record VS within one hour of completion
5. perform post-transfusion blood work if ordered
6. continue to observe for s/s of transfusion reaction
7. document
110
what is a tracheostomy tube
surgical incision in the trachea below the larynx
4-10 mm tube inserted through stoma into trachea
111
what complications are associated with tracheal suctioning?
hypoxemia, cardiac arrhythmias, atelectasis, mucosal trauma, infection, increased intracranial pressure, laryngospasm, aspiration
112
why are trach pts more prone to lung infections?
by bypassing all functions of the upper airway the nose doesn't filter, humidify, and warm the air before entering the lungs
113
why is suctioning done prior to performing trach care?
to remove secretions to not occlude the outer cannula when the inner cannula is removed, decrease the risk of airway being blocked by secretions
114
what signs and symptoms indicate a need for tracheostomy suctioning?
low O2 sats, cyanosis/pallor, tachypnea, restless/anxious, gurgling voice, crackles/gargles in the upper airway
115
indications for tracheal suctioning
- improve respiratory status
- maintain a patent airway
- prevent infection caused by retained secretions
116
what pressure is tracheostomy suctioning done at?
80-120
117
describe the process of tracheal suctioning
1. sterile glove in dominant hand guides the suction catheter and non dominant remains non-sterile
2. insert into the trach until you meet resistance at the bifurcation of trachea then withdraw 1 cm BEFORE starting intermittent suctioning
3. NO SUCTION when inserting
4. MAX 10 seconds from insertion to withdrawal, max 2 times with 1 min of hyperoxygenation in between
118
complications of suctioning
1. hypoxemia/hypoxia
2. atelectasis
3. mucosal damage
4. infection
119
what is involved in tracheostomy care?
changing the inner cannula and dressing/tube tie change
120
how often do you perform tracheostomy care?
q12 PRN
121
how do you calculate a safe pediatric dose with the body weight method?
1. convert child's weight from pounds to kilograms (1lb = 2.2kg) [ROUND TO TENTHS]
2. multiply mg/kg by the child's weight in kg to get the maximum and minimum recommended dose
3. compare the ordered dose to recommended dose and decide if it is safe
4. determine the dose (D/H xQ = __ )
122
indications for use of restraints
pacing/wandering, unsafe mobility, impaired safety awareness, unable to follow instructions, imminent danger to self or others, pulling tubes/lines/wires etc..
123
alternatives to restraints
reorienting, 1:1 added care, repositioning, distracting, de-stimulate the environment, simple statements, basic needs, assess pain, cover IV lines etc..
124
what is the least restraint policy
use all possible alternatives and restrain only if necessary for the shortest amount of time
125
what do you document after tracheostomy care?
1. amount, consistency and color of secretions
2. number of suction attempts
3. respiratory and cardiopulmonary status pre and post procedure
4. skin color if indicated
5. how pt tolerated procedure
126
